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/ SAN JOAQUIN LOCAL HEALTH DISTRICT-T __ <br /> FOR OFFICE USE: f/ 1601 E. Hazelton Ave. , Stockton, Calif. <br /> A 4- <br /> Telephone: (249) 465-6781 <br />` APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No.� <br /> I THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> f <br /> i JOB ADDRESS/LOCATION ',-7cfr �I _ CENSUS TRACT S 0 <br /> k Owner's Name l'�l oo E' d Ov /5/ Phone -3 <br /> Address - I �. City RT R"P A/ <br /> HENNTNGS EROS. DRILLING C6., INC'. <br /> Contractor's Name I License # Phone <br /> 000 W. <br /> RUMBLE <br /> ROAD <br /> TYPE OF WORK (Check): NEW WELLDEEPEN /-7RECONDITION /? DESTRUCTION /-7 - <br /> PUMP INSTALLATION / PUMP REPAIR / PUMP REPLACEMENT /? <br /> Other '/-7 <br /> DISTANCE TO NEAREST: SEPTICjTANK SEWER LINES PIT PRIVY <br /> )( SEWAGEDISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> i <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS. �- 1 <br /> Industrial I Cable Tool Dia, of Well Excavation y -Z <br /> X _ Domestic/private t Drilled Dia, of Well, Casing i <br /> Domestic/public Driven Gauge of Casing <br /> / q,x, <br />. � Irrigation I Gravel Pack Depth of Grout Seal <br /> Other X Rotary Type of Grout <br /> I Other Other Information <br /> PUMP INSTALLATION: Contractor <br /> Type o1f Pump H.P. <br /> I <br /> PUMP REPLACEMENT: / / State Work Done <br /> PUMP REPAIR-:-.;,�,_. /- / -State-Work Done <br /> ,DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> -- Describe Material and Procedure <br /> I <br /> 4` I <br /> I hereby agree to comply wfth' all laws and regulations of the San Joaquin Local Health District <br /> and the State ,of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> I <br /> SIGNED <br /> ..� TITLE � <br /> (OXAW PLOT LAN ON REVERSE SIDE . <br /> F DE TT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTS DATE. - zo ` <br /> ADDITIONAL COMMENTS: — <br /> PHASE II GROUT INSP C ION PHASE III FINAL INSPECT <br /> INSPECTION BY ZQ DATE , „� INSPECTION BY BATE <br /> CALL, FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECTION. <br /> 'E H 1426 7/72 1M C <br />